ACA Repeal: The Latest

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The Senate proposal is out. The proposed law is 142 pages of (perhaps unnecessary) complexity, and, given the rushed nature, probable errors. But it’s out.

It’s not out in time to prevent damage for 2018.

  • Withdrawal of insurers: Aetna notified agents that it will be withdrawing from individual markets in 18 states. Notices to policy holders will be sent on or about July 1st. Other firms have announced withdrawals from a few states, most particularly Iowa and Indiana.
  • Heavy rate increases: Insurers in the individual market in Virgina have asked for a 30% rate increase for 2018, based on uncertainty about whether the Federal government will continue subsidies for health insurance. Insurers in NY State have asked for a 16.6% increase. Most other states will be in that range.

The proposal represents a mixed signal for consumers.

  • Pre-existing conditions: The Senate version conforms with the House version in requiring insurers to cover people with pre-existing conditions. HOWEVER . . .
  • Coverage: States can apply for waivers allowing insurers to reduce the coverage they provide. Services required by people with pre-existing conditions may not be covered.
  • Medicaid: The bill supports a contraction of Federal Medicaid funding, but delays the start of cutbacks until 2021. The House version started cuts in 2020, an election year. The Senate version of the cuts are later and deeper.
    • The Medicaid expansion was an increase of the income limit for eligibility from 100% of poverty level to 138%.
    • Under the Senate version people making more than 100% of poverty level would be prevented from enrolling in Medicaid starting in 2020.
    • All Federal funding for the expansion would be limited in 2023.
    • The impact on the Medicaid program for children, CHIP, is unclear at this time.
    • Inflation adjustments for Medicaid funding would be changed from an index based on medical costs to the overall Consumer Price Index (CPI), which would reduce annual increases in funding in all future years. (See graph.) (4) The focus of this change is strictly on reducing Federal spending, not helping consumers. Federal payments would lag behind increases in medical costs — who pays the difference?fredgraph
  • Tax credits to help pay for insurance: The House version based subsidies on age; the Senate version reverts to income as the basis, consistent with the existing ACA rules. However,
    • The Senate version reduces the maximum income eligible for these subsidies, making some people now receiving subsidies ineligible for them in the future. On low low end, the Senate version makes subsidies available for people earning below below poverty level who might not be eligible for Medicaid in their state. The Senate version maintains cost-sharing subsidies for insurers through 2019.
    • The Senate version reduces the amount of subsidy people receive, increasing out of pocket costs for everyone, and especially for those between age 50 and 64.
  • Planned Parenthood: Both House and Senate versions remove funding for Planned Parenthood.
  • Tax reductions for affluent households: The Senate and House versions are in agreement on this; the reductions remain intact.
  • Individual mandate: Penalties for not having insurance are eliminated.

Sticking points:

  • For conservatives: Treating healthcare as a human right. They would rather see the ACA eliminated without replacement.
  • For moderates and those in competitive districts

Collateral damage:

  • Insurance coverage: There’s a debate as to how many people will not have insurance coverage with this law.  Estimates vary between 13 and 23 million.  The reasons for the variance in estimates include:
    • Time frame — loss of coverage will build over time as insurance costs increase and subsidies don’t.
    • Medicaid — how many people will lose coverage under Medicaid. That impacts more people than you would expect. Most people don’t have Long Term Care insurance, and Medicaid has become the prime vehicle for paying for home health aides and nursing home costs. Since nursing home costs average nationally more than $9,000 per month and Medicare pays for only the first 100 days, there are a lot of middle income families that will be in trouble. Even some moderately affluent families will be affected, and the poor . . . forget about it.
  • Tax increases: Healthcare for the uninsured will fall back on emergency rooms, largely of public hospitals. That will drive costs and budget increases and increases in local taxes. Tax savings for the rich will mean tax increases for everyone else.
  • Economic stagnation: The US is a consumer economy. I’ve argued previously that money siphoned from consumers for education, housing and healthcare is money they can’t spend for anything else. One analyst sees 1.1 million jobs disappearing by 2020 with passage of the AHCA. (3)

 


Sources:

  1. M. J. Lee, Tami Luhby, Lauren Fox, Phil Mattingley, “Senate GOP finally unveils secret health care bill; currently lacks votes to pass,” CNN, 22 June 2017. http://www.cnn.com/2017/06/22/politics/senate-health-care-bill/index.html
  2. Stephanie Armour, Kristina Peterson and Louise Radnofsky, “Battle Lines Drawn on Health Care,” The Wall Street Journal, 23 June 2017, P. A1.
  3. Josh Bivens, “Millions of people have a lot to lose under the AHCA,” Economic Policy Institute, 21 June 2017. http://www.epi.org/publication/millions-of-people-have-a-lot-to-lose-under-the-ahca/?utm_source=Economic+Policy+Institute&utm_campaign=50e819bfcb-EMAIL_CAMPAIGN_2017_06_23&utm_medium=email&utm_term=0_e7c5826c50-50e819bfcb-58834721&mc_cid=50e819bfcb&mc_eid=0541ad0f29
  4. Federal Reserve Bank of St. Louis, Economic Research. Chart downloaded 25 June 2017. https://fred.stlouisfed.org/graph/?id=CPIMEDSL,
  5. Bob Bryan, “Unveiled: The Secret Senate Healthcare bill,” Business Insider, 22 June 2017. http://www.businessinsider.com/senate-healthcare-bill-trumpcare-ahca-details-2017-6

Cancer: Speed of Starting Treatment Matters

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We already know that early detection of cancer

  • Reduces the time required for treatment
  • Reduces the cost required for treatment
  • Improves the outcome in terms of five-year survival rate

Cancer screening is invaluable.

Now a new study from the Cleveland Clinic shows that the time lapse between detection of cancer and the start of treatment also matters. Each week that passes between diagnosis and the start of treatment impacts the five-year survival rate.

Longer delays between diagnosis and initial treatment were associated with worsened overall survival for stages I and II breast, lung, renal and pancreas cancers, and stage II colorectal cancers, with increased risk of mortality of 1.2 percent to 3.2 percent per week of delay, adjusting for comorbidities and other variables. (1)

In the example of stage I non-small cell lung cancer, the five-year survival rate is

  • 56% if treatment starts within 6 weeks versus
  • 43% if treatment starts later

The problem is that the length of time between diagnosis and treatment has been increasing since 2004.

What you need to consider:

  • With cancer, once diagnosed, time is of the essence.
  • Checkups and screening are essential.
  • Cancer can strike at any age.

Sources:

  1. Cleveland Clinic. “Time to initiating cancer therapy is increasing, associated with worsening survival: Based on US analysis of common solid tumors in study population of 3.6 million.” ScienceDaily. ScienceDaily, 5 June 2017. <www.sciencedaily.com/releases/2017/06/170605151949.htm>.

Deprescribing medication

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There are two relatively new  terms in medical jargon that are worth knowing:

  • Polypharmacy: Taking a large number of prescription medications.
  • Deprescribing: Systematically reducing or eliminating medications that have been prescribed for a patient.

Pharmaceutical companies obviously provide information about when a drug should be used and about side effects that might indicate that the drug should not be used.

What’s rare is information about when a drug ceases to be effective or of value to the patient. Thus as people age, they tend to add prescriptions, and continue them beyond the point of the drug having any real value to the patient.

Dr Farrell notes that at her hospital in Ottawa, it is not unusual to see a patient on 25-30 medications. “Frequently, a medication is started to see whether it will help with certain symptoms—almost like a diagnostic test—but then the medication is never stopped,” she explains. “Ten years go by, and the family doctor retires or dies, and the patient sees a new family doctor who doesn’t know why the drug was prescribed in the first place but is scared to stop it. I see patients in their 80s and 90s who have been on a medication for 30 years, and no one can remember why they are taking it.” (1)

The Canadians are ahead of the US in tackling this issue, even though drug costs are substantially lower in Canada than in the US.

Dr. Barbara Farrell is a clinical scientist at the Bruyère Research Institute and the C.T. Lamont Primary Health Care Research Centre, and assistant professor in the Department of Family Medicine, University of Ottawa, Canada. She is a cofounder of the Canadian Deprescribing Network and codeveloper of deprescribing.org, a website for the dissemination and exchange of information about deprescribing approaches and research. (1)

Her Canadian team is in the process of developing guidelines for reducing or eliminating the medications prescribed for a patient.

Why is this important?

  • Some drugs lose or even reverse their effects over time (e.g., the cancer drug, tamoxifen, which can be used for no more than five years)
  • A drug to fight one illness may aggravate another condition the patient develops
  • There may be long term interactions or complex interactions from combinations of four or more medicines
  • A drug may simply cease to be of value to a patient. If a patient is confined to bed with dementia, does the cholesterol level really matter?
  • Costs

What you should consider:

  • Do you know what the medications you are taking do?
  • Have you talked with your doctor about whether you could reduce dosages?
  • Have you talked with your pharmacist recently about drug interactions and whether there are any long term risks to using a drug?

Ultimately, you’re the custodian of your body. Like a house or a car, your body needs maintenance and you need to be in control.


Sources:

  1. Lisa Brooks, “Easy to Start, Hard to Stop: Polypharmacy and Deprescribing,” Medscape, 1 June 2017. http://www.medscape.com/viewarticle/880716?nlid=115489_1521&src=WNL_mdplsfeat_170606_mscpedit_wir&uac=153634BV&spon=17&impID=1362583&faf=1
  2. Deprescribing.org/
  3. I A Scott et. al., “Reducing inappropriate polypharmacy: the process of deprescribing,” JAMA Intern Med. 2015 May;175(5):827-34. doi: 10.1001/jamainternmed.2015.0324.
  4. Matthew Clark, “Deprescribing Medications,” Indian Health Service, undated.

ACA Repeal: Update

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I’ve been quiet about the recent AHCA legislation. Frankly, the House bill isn’t good for ben_franklinmost Americans, but the assumption is that the Senate will heavily revise the bill before it has a chance for passage. So it’s hard to say what the final legislation will be at this point.

Then it goes to conference committee and the result will return to each chamber for a vote.  So this is a long way from being done.

There are a number of articles enumerating the problems in the House bill. The major issues are

  • Loss of health insurance for millions of Americans
  • Impact on the solvency of hospitals and clinics serving rural areas — where most of the poor live
  • Reductions in Medicaid coverage, especially for children
  • Allowing states to reduce coverage standards in insurance (depart from the ACA’s Minimum Essential standards) — reducing what the insurance buyer gets for their money
  • Raising costs drastically for consumers between the ages of 50 and 64 (1)

With all of these issues, we are still expecting the repeal bill to result in sharply higher premiums for health insurance.

The only positives in this bill are tax reductions for the wealthy.

My major concern is with health screening and checkups. The ACA recognized that the main way to reduce health care expenditures is through early detection and treatment of disease. Removing access to doctors means later detection and much higher costs.

Example: breast cancer, cost of treatment by tumor stage

Stage

0                                         $71,909

I/II                                      $97,066

III                                      $159,442

IV                                      $182,655 (2)

Reduction is access to health care is a commitment to higher medical spending or to reduction of life expectancy.


Sources:

  1. Harris Meyer, “15 quick facts from CBO report on Obamacare repeal bill,” Modern Healthcare, 24 May 2017. http://www.modernhealthcare.com/article/20170524/NEWS/170529946?utm_source=modernhealthcare&utm_medium=email&utm_content=20170524-NEWS-170529946&utm_campaign=mh-alert
  2. Helen Blumen, Kathryn Fitch, Vincent Polkus, “Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service,” Am Health Drug Benefits. 2016 Feb; 9(1): 23–32.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/

The Intelligent Patient

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Medicine isn’t about just doing what the doctor tells you to do. Quality of life is ben_franklinsomething a doctor cannot determine. That’s a call that the patient has to make.

Let me explain by example. Prostate cancer is a difficult form of cancer, traditionally treated by removal of the prostate gland. The unfortunate side effects of that surgery are urinary incontinence, and erectile/sexual dysfunction.

A few years ago, it was discovered that some prostate cancers grow so slowly that the cancer would pose no meaningful threat to the patient. This led to an alternative approach to treatment called “watchful waiting” — basically, monitoring the growth of the cancer and doing nothing as long as the growth rate remains slow.

Now we have new research that  both documents the the impact of prostate surgery and raises questions about the value of it.

A paper presents follow-up research with prostate cancer patients, some of whom had undergone prostate cancer surgery. The follow-up was conducted approximately 19.5 years after the surgery. The key findings are:

  • Those who had the surgery reduced their risk of death from all causes by 5.5%. That is, 66.8% of those under watchful waiting died, as did 61.3% of those who had the surgery.
  • A separate analysis determined that patients characterized as “high risk” or “low risk” at the time of the decision about surgery saw no reduction in the risk of death. The entire benefit accrued to those in the “intermediate risk” category. However, due to complicating issues, there’s a debate about how much benefit even they received.

The question for the patient (not the doctor): is the surgery worth the pain and side effects for a 5.5% decreased risk of dying?

The recommendation of the doctors presenting these results is the separation of diagnosis and treatment decisions. A specific course of treatment should not be an “automatic” follow-on to a diagnosis.

My point in writing this is that the cost/benefit analysis you have to apply to this decision is true for other diseases and treatments as well. Ultimately, you as the patient need to decide what’s right for you. And, as always, consult other independent medical professionals for second and even third opinions.

CAVEAT: As always, I’m not a doctor. I’m a researcher. My role is to make you aware of items you should know or consider in making decisions, but I’m not making the decision for you, or providing medical, legal or financial advice. Your life is yours to control and manage.


Sources:

  1. Roger Li, MD, Ashish M. Kamat MD, and Wayne B. Duddlesten, Professor, MD Anderson Cancer Center, “AUA 2017: Radical prostatectomy versus observation for early prostate cancer: follow-up results of the prostate cancer intervention versus observation trial,” conference presentation, 2017 AUA Annual Meeting – May 12 – 16, 2017 – Boston, Massachusetts, USA

Childhood Weight, Adult Depression and . . . Bullying? Time to Connect the Dots?

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Being narrow-minded affects people in a broad range of occupations, including ben_franklinacademia. Most people working in one field don’t see what people in related field are doing. Truth literally “falls between the cracks” separating different areas of work.

The people to whom we ascribe brilliance, like Steve Jobs, are those who are able to gather information from a broad array of sources and disciplines and connect the dots to form a coherent picture that others can’t see. Others fail to see the same because they don’t look. They limit what they see to the portion of the world in which they live and work.

Now for an example . . .

In an earlier blog, I reported on research linking being a victim of bullying to depression and health issues in high school. (1) The theory is that the impact of bullying can last well into adulthood.

A new study by Deborah Gibson-Smith from VU University Medical Center in the Netherlands and colleagues reports on a link between being overweight as a child and adult depression. The study doesn’t explain how extra pounds as a child effect adult emotions; it simply reports a statistical relationship. (2) The premise is that it has something to do with self-image.

My theory: Overweight children get bullied, and that bullying causes negative attitudes and behaviors that can linger into adulthood. It’s a simple idea, testable, and provides a concrete mechanism for converting excess weight as a child into adult depression.

However, because we have one group studying the effects of weight, and a different group studying the effects of bullying, apparently no researchers have tried to connect these dots.

Does that make sense?


Sources:

  1. Crain, “Bullying and Depression.”
  2. European Association for the Study of Obesity. “Being overweight in childhood may heighten lifetime risk of depression.” ScienceDaily. ScienceDaily, 18 May 2017. <www.sciencedaily.com/releases/2017/05/170518221006.htm>.

 

 

NIH on COPD: Missing the Point, Too

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When you politicize science — or try to — you create new opportunities to waste taxpayer ben_franklinmoney.

The NIH has announced a new “National Action Plan” to combat COPD, the third leading cause of death in the US.

The third leading cause of death in the United States, chronic obstructive pulmonary disease, or COPD, affects 16 million Americans diagnosed with the disease and millions more who likely do not know they have it. The disease, which costs Americans more than $32 billion a year, can stifle a person’s ability to breathe, lead to long-term disability, and significantly affect quality of life. (1)

In building the action plan, NIH assembled workshops involving patients, medical professionals, academics, and pharmaceutical industry representatives.

That’s the problem.

COPD isn’t curable, but it may be preventable. However, to prevent it, you have to focus on causes, not treatments after the disease has developed. What are the causes?

  • Smoking — 20 to 30% of smokers develop COPD according to the Mayo Clinic, although others may have reduced lung function (4)
  • Long term exposure to industrial dust and chemical fumes (e.g., the famous “black lung” of coal miners)
  • Long term exposure to air pollution
  • Premature birth with lung damage
  • Genetics

Some authorities try to put the entire blame for COPD on the cigarette industry. That’s a simple answer, and as usual with simple answers, it’s probably not correct. Mayo’s analysis is probably more prudent, splitting blame between cigarettes and environmental factors.

Here’s the issue:

  • The workshops didn’t include representatives of the industries creating the pollution that causes COPD. Where are reps for the auto, power, chemical or cigarette industries?
  • Further, the current administration has made a clear statement that environmental issues don’t matter.

We can anticipate that this initiative will focus on more expensive treatments instead of prevention. That simply drives healthcare costs higher without solving anything.


Sources:

  1. National Institutes of Health, “COPD National Action Plan aims to reduce the burden of the third leading cause of death,” press release, 22 May 2017. https://www.nih.gov/news-events/news-releases/copd-national-action-plan-aims-reduce-burden-third-leading-cause-death
  2. WebMD, “COPD (Chronic Obstructive Pulmonary Disease) – Causes,” undated. http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-cause
  3. Ann Pietrangelo, “Everything You Need to Know About Chronic Obstructive Pulmonary Disease (COPD),” Healthline, 25 October 2016. http://www.healthline.com/health/copd
  4. Mayo Clinic, “COPD – symptoms and causes,” undated. http://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/dxc-20204886